Do the Payers Understand Nerve Blocks for Post-Anesthesia Pain?

Some payers are sowing confusion regarding whether nerve blocks placed for the management of postoperative pain are separately payable.

ABC’s Alert dated April 8, 2013 noted that Noridian LLC, the Medicare Part B (physician services) contractor for ten states in the Western U.S. had published a proposed policy that would prevent payment for peripheral nerve blocks placed preoperatively to reduce postoperative pain. Specifically, the draft policy (Local Coverage Determination, or LCD) entitled Nerve Blockade: Somatic, Selective Nerve Root, and Epidural stated that: “Providers should not expect separate payment for the establishment of epidural or other pain blocks unless the block is placed following discharge from PACU due to documented inadequate pain control.”

The proposed new rule received considerable attention, as it would have reversed the longstanding principle that the purpose of a nerve block placed to manage surgical pain, and not its timing, determines whether the block is separately payable from the anesthesia service.  Most payers continue to follow the rule spelled out in the latest version of the National Correct Coding Initiative (CCI) Policy manual, Version 15.3:

Under certain circumstances an anesthesiologist may separately report an epidural or peripheral nerve block injection (bolus, intermittent bolus, or continuous infusion) for postoperative pain management when the surgeon requests assistance with postoperative pain management. . . . An epidural or peripheral nerve block injection . . . for postoperative pain management in patients receiving general anesthesia, spinal (subarachnoid injection) anesthesia, or regional anesthesia by epidural injection . . . may be administered preoperatively, intraoperatively, or postoperatively.

As explained in our earlier Alert, the Medicare LCD adoption process requires the Medicare Administrative Contractor to solicit comments from the practicing physician community and to hold open meetings to discuss the draft LCD.  During the comment-and-discussion period for the proposed Nerve Block LCD, which will continue until July 11, 2013, Noridian was apparently persuaded to modify its original draft.  The current revision includes the following language:

Reimbursement for the control or management of acute pain in the immediate postoperative period is generally packaged into the payment for the surgical procedure. However, if a need for transfer of pain management is documented and ordered by the surgeon and the accepting provider documents the need for an acceptance of transfer of care, separate reimbursement may be made for the service.

The above statement is consistent with the CCI and other expressions of the standard policy.  It is inconsistent, however, with Noridian’s  preoperative pain block policy for Medicare Part A (hospital services), which was incorporated into the draft LCD as “part of a general housecleaning effort to reconcile Part A and Part B LCDs,” according to a Noridian official quoted in Common coding challenges: Draft pain block policy contain stricter post-op provisions published in Anesthesia & Pain Decisions (“Pink Sheets”) on June 1, 2013.  The Part A text provides that:

Reimbursement for the control or management of pain in the immediate postoperative period is packaged into the payment for the procedure, surgical or anesthetic—regardless of the method by which the care provider, including the anesthesiologist, decides to manage pain. Following discharge from the post-anesthesia care unit (PACU), the medically reasonable and necessary placement of regional or peripheral pain blocks or initiation of other new pain interventions or “top-up” dosing may be reimbursable. Providers should not expect separate payment for the establishment of epidural or other pain blocks unless the block is placed following discharge from PACU due to documented inadequate pain control.

In a letter to Noridian dated June 13, the American Society of Anesthesiologists pointed out the conflict between the Part B and Part A principles.  The ASA further noted the adverse consequences to patients of waiting until after discharge from the PACU to initiate pain interventions, quoting the following statement from the recent white paper The Impact of Regional Anesthesia on Perioperative Outcomes by James R. Hebl, MD and Joseph M. Neal, MD:

[I]n the absence of performing preemptive (i.e., preoperative) regional anesthesia, clinicians will be forced to administer higher doses of intravenous opioids to patients during surgery and within the Post-Anesthesia Care Unit (PACU) which will contribute to an increased risk of sedation, obstructive breathing patterns, respiratory depression, postoperative nausea and vomiting, and ileus formation – all of which are known to contribute to patient morbidity, prolong hospital stays, and increase the cost of medical care.

We hope that Noridian will eliminate the inconsistency and, in the final version of the LCD, align its Part A policy with good clinical care and with the standard policy that pays for the preoperative placement of a nerve block as long as the adequacy of the intraoperative anesthesia is not dependent on the block. 

Other Payers

Noridian is not the only payer to be having trouble understanding preoperative pain blocks.  In its “Reimbursement Policy” on Modifier 59 dated  May 20, 2013, Cigna states that “Documentation supporting the use of the Modifier 59 should be submitted identifying that the peripheral nerve block was rendered ONLY for postoperative pain management and is unrelated to the anesthesia provided for the surgery itself.” (Emphasis in original.)   The standard rule is, however, that “A provider may bill for a regional anesthetic technique as a service separate from the anesthetic if the regional technique is EMPLOYED PRIMARILY for postoperative analgesia.” (Emphasis supplied.) (ASA Statement on Reporting Postoperative Pain Procedures in Conjunction with Anesthesia, last amended October 20, 2010; similarly, CPT Assistant, Vol.. 11, Issue 10, October 2001.) 

It may be impossible for the anesthesiologist to attest that the exclusive goal of placing a block preoperatively was to manage postoperative pain; intra-operative analgesia is usually a desired secondary effect. Cigna itself appears to recognize that the issue is whether the primary purpose of the block is for postoperative pain management just three paragraphs beyond the statement quoted above, stating, “Peripheral nerve block codes should not be reported separately on the same date of service as a surgical procedure if used as the primary anesthetic technique or as a supplement to the primary anesthetic technique.” 

Confusion on the part of Wisconsin Physician Services (WPS) has also come to our attention, in the form of a statement in an unfavorable decision on a payment redetermination request:  “Per recent clarification received from the Contractor Medical Director (CMD), if a nerve block precedes general anesthesia, it is not a separately payable service regardless of who performed it.”  This “clarification” does not appear in any WPS LCD or other written policy, but it is of concern, given the saga of the Noridian LCD.

Documentation Confusion

One reason for Noridian’s interest in preoperative pain blocks is the adequacy of the documentation submitted to show that the block is a distinct service, justifying the use of modifier -59.  According to the article in the Pink Sheet, “An email to ASA members . . . notes that Noridian’s audits have revealed poor documentation of the surgeon’s request for post-op pain management and the procedure itself.”   A memo to participating physicians from Cigna dated May 21, 2013, by making the submission of supporting documentation together with the claim a condition for payment, suggests that the problem of insufficient documentation extends to other payers.

The proposed Noridian LCD goes farther than other payer policies, requiring that the surgeon—not the anesthesiologist—document his or her order for postoperative pain management as well as the rationale for the order. If the LCD is finalized as it reads now, it will no longer be sufficient  if Noridian is the carrier, for the anesthesiologist to include a statement such as “right-sided axillary postop pain block as requested by the surgeon” in the procedure note.

Secondly, if the proposed LCD becomes final, claims submitted to Noridian will  also need to document the anesthesiologist’s acceptance of the transfer of care.

It would appear that there is considerable variation in the location of the information supporting the post-op pain block.  The Cigna Reimbursement Policy cited above states that “Recommended documents that typically include this type of information are the Operative Report and the Anesthesia Record.”  ABC recommends that a separate block note be readily available in case of denial or audit. The ASA Statement asserts that “One excellent means of portraying that the block was a postoperative analgesic is to dictate or record its conduct in the chart in a location separate from the anesthetic record.” (Emphasis in original.)

The ASA letter to Noridian notes that “Documentation may come from a variety of sources including an anesthesia record, handwritten progress/procedure note entries, or other multiple locations within an electronic health record” and requests “clear education from Noridian to the surgical and anesthesiology communities describing the reasons for the requirements and examples of acceptable pathways to meet the documentation elements.”

If and when Noridian provides such education, and as the changing requirements become more definitive, we will certainly keep our readers informed.